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, • } AM \ 5 ss� i . R a � �� 52 s„ to ot-i t <br /> �� Manufactured Home Trip Permit Application,, <br /> i:'' i' Department of Consumer and Business Services <br /> Building Codes Division <br /> 5 <br /> 1535 Edgewater St. NW, Salem, Oregon •Phone: 503-378-4530 • Fax: 503-378-4101 . <br /> _.. . Web: oregon.gov/bcd • Email: tnhods.bcd@oregon.gov . <br /> This application must be submitted with a valid tax certification from the county in which the home is currently located, <br /> as well as the county the home is moving to. A valid tax certification is one that has been certified by the county and <br /> submitted before the expiration date provided by the county at the time of certification. <br /> APPLICANT INFORMATION <br /> Name:Amber Homes LLC <br /> Address (includingcity, state, and Z1P):221 Main St#2039, Lot Altos CA, 94023 <br /> Phone:.(210)692-4249 <br /> Email:inventory@amberhomes.us <br /> . TRANSPORTER INFORMATION <br /> Name:Superior Home Transport LLC <br /> Address(including city,state, and ZIP):111 SOUTH SECOND STREETJEFFERSON, OR 97352 <br /> Phone:(541) 327-7805 <br /> Email:ritahartzell@gmail.com <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): <br /> Manufacturer:Fleetwood Model:Weston Super Value -Year:2022 <br /> HUD label numbers:ORE560105/06 <br /> Serial numbers:FLE2100R21-22870 A/B <br /> ADDRESS INFORMATION <br /> Current location(including city, state,ZIP): 2655 Progress Way, Woodburn OR, 97071 County:Marion <br /> Manufactured home park name, if applicable: <br /> .❑ Oregon dealer lot Dealer name:Fleetwood <br /> ❑ Out-of-state dealer lot Dealer name and contact information: <br /> Placement location(including city, state,ZIP):4915 Swegle Road NE, Lot 58 Salem OR, 97301 County:Marion <br /> Manufactured home park name, if applicable:Sunset Village <br /> - ❑ Oregon dealer lot Dealer n me: <br /> Applicant signature: % ) J <br /> Amount: <br /> Trip permit(per section) $5.00(70511-1195) $ <br /> TOTAL $ <br /> Make check or money order payable to Department of Consumer and Business Services. If paying by credit card,applicant <br /> . must sign credit card information box.Do not send cash.Secure fax: 503-947-2333 <br /> El Visa ❑MasterCard ❑Discover Phone:( ) Department use only <br /> $ <br /> ' Cardholder signature Amount <br /> Name of cardholder as shown on credit card <br /> . Credit card number Expiration <br /> iCBS <br /> Conumer and <br /> Busi Services <br /> 440-5225(10/17/COM) <br />